Remote Medical Director, Utilization Management

Clover Health; United States; Remote; USD 250,000 - 320,000; Full time

Benefits offered by this job

Equity opportunities

401k matching

No-Meeting Fridays

Remote-first culture

Job summary

Clover Health is seeking a Medical Director, Utilization Management, to lead evaluation of outpatient referrals and inpatient admissions for medical appropriateness. The physician will apply Medicare Coverage Determinations and Clover policies to determine medical necessity and alternative plans.

The role focuses on guiding UM processes, mentoring staff, and advancing Clover’s clinical guidelines while maintaining licensure and board-certification standards across the organization.

Qualifications

• MD or DO degree.
• Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or related specialty.
• Unrestricted license to practice medicine in a U.S. state.
• Minimum of five years of clinical experience.
• At least one year of Utilization Management reviewer experience.
• Medicare Advantage experience.

Responsibilities

• Participate and support the Clover Health Utilization Management processes.
• Support Quality improvement initiatives for Clover members.
• Review Utilization Management authorization requests for medical necessity.
• Evaluate authorizations for outpatient referral, inpatient direct admissions, post-acute referrals, and pharmacy within established timelines.
• Perform peer-to-peer discussions and build collaborative relationships with community and hospital Providers.
• Provide mentoring and coaching to UM nurses to strengthen Utilization Management effectiveness.
• Support the ongoing development of Clover Health’s clinical guidelines and policies.
• Maintain credentials as required for employment with Clover Health.

Skills

MD or DO

Board Certification

Clinical experience

Utilization Management

Medicare Advantage

Education

MD/DO degree

Tools

License to practice in US

Job description

Clover Health is seeking a Medical Director, Utilization Management, to lead evaluation of outpatient referrals and inpatient admissions for medical appropriateness. The physician will apply Medicare Coverage Determinations and Clover policies to determine medical necessity and alternative plans.

The role focuses on guiding UM processes, mentoring staff, and advancing Clover’s clinical guidelines while maintaining licensure and board-certification standards across the organization.